The Use of Multi-Stakeholder Coalitions to Integrate Healthcare and Social Services The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Lapedis, Jeremy. 2017. The Use of Multi-Stakeholder Coalitions to Integrate Healthcare and Social Services. Doctoral dissertation, Harvard T.H. Chan School of Public Health. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:42066968 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA THE USE OF MULTI-STAKEHOLDER COALITIONS TO INTEGRATE HEALTHCARE AND SOCIAL SERVICES JEREMY LAPEDIS A DELTA Doctoral Thesis Submitted to the Faculty of The Harvard T.H. Chan School of Public Health in Partial Fulfillment of the Requirements for the Degree of Doctor of Public Health Harvard University Boston, Massachusetts. May 2017 Dissertation Advisor: Richard Siegrist Jeremy Lapedis The Use of Multi-Stakeholder Coalitions to Integrate Healthcare and Social Services Abstract The United States healthcare system is looking to reduce healthcare costs and improve healthcare outcomes by traversing traditional healthcare boundaries to address not only the clinical but also the social needs of patients. Coalitions between healthcare systems, social service organizations, and government entities are one way to address gaps in the healthcare and social service systems. The Washtenaw Health Initiative (WHI) is a multi-stakeholder collaborative in Michigan working to integrate healthcare and social services through use of the Collective Impact model. Using participant observation and in-depth interviews, this dissertation aims to 1) evaluate the implications of WHI’s alignment with and departures from the Collective Impact model and other coalition theories and 2) to explore opportunities and challenges for all coalitions working to integrate healthcare and social services. The WHI is partially aligned with the Collective Impact model, in that it has a common agenda of promoting community connections and a strong backbone organization. It does not strongly align with the other pillars of Collective Impact: shared measurement, mutually reinforcing activities, and continuous communication. Drawing on other coalition theories, the WHI may benefit from more clearly defined roles and structure, explicit meeting norms, and a process for embarking on new activities—including an emphasis on community engagement. Through these changes, the WHI may become more effective by aligning its approach to creating change and its activities with its mission. Coalitions have an opportunity to help providers navigate the tricky interface between healthcare and social services by sharing and collaborating on different approaches to addressing ii patients’ social needs. Yet, to effectively address the root causes of social conditions, coalitions face the challenges of engaging their diverse members, equalizing power dynamics, and building trust. Overcoming these challenges requires strengthening relationships amongst coalition members through active facilitation to create an environment to hold difficult conversations about power, resource distribution, and problems in the coalition’s local healthcare system. By using coalition models to refine processes and structures, multi-stakeholder coalitions can build an environment which uncovers and addresses the underlying issues that cause gaps in the U.S. healthcare and social service systems. iii Table of Contents Abstract ......................................................................................................................................................... ii List of Figures with Captions ........................................................................................................................ vi Acknowledgements ..................................................................................................................................... vii I. Analytic Platform................................................................................................................................... 1 A. Introduction ...................................................................................................................................... 1 B. The Michigan State Innovation Model and Its Precursors ................................................................ 2 C. Local Context and Host Organization ................................................................................................ 5 D. The Broader Context of Healthcare and Social Services ................................................................. 13 E. Integrating Healthcare and Social Services: Current Thinking and Challenges .............................. 25 F. Coalitions and Organizational Behavior .......................................................................................... 32 II. DELTA Guiding Questions, Activities, and Methods ........................................................................... 57 A. Guiding Questions ........................................................................................................................... 57 B. SIM Design Activities ....................................................................................................................... 61 C. WHI Process Evaluation .................................................................................................................. 66 III. Results ............................................................................................................................................. 69 A. The WHI’s Most Salient Agenda is Promoting Community Connections ........................................ 69 B. The WHI’s Strengths and Weakness Reflect Those of the Backbone Organization........................ 75 C. Cultivating Member Engagement of a Maturing Coalition Requires Clear Structures and Intentional Facilitation, Which Are Not Always Present Throughout the WHI ...................................... 78 D. Goals, Measurement, and Activities Should Align with a Coalition’s Purpose ............................... 92 E. Community Engagement is Slow, Challenging, and Necessary ...................................................... 96 F. The WHI Is Viewed Differently by Those in the Healthcare Sector and Those Primarily in the Social Service Sector ........................................................................................................................................ 102 IV. Conclusions ................................................................................................................................... 110 A. What are the implications of the WHI’s alignment with and departures from Collective Impact and other coalition models? ................................................................................................................. 110 B. What are the specific opportunities and challenges that coalitions seeking to integrate healthcare and social services face that individual organizations do not? ............................................................. 116 C. Areas for future work .................................................................................................................... 125 V. Bibliography ...................................................................................................................................... 128 VI. Appendices .................................................................................................................................... 142 Appendix I: SIM Governance Model ..................................................................................................... 142 Appendix II: SIM Care and Case Manager Survey ................................................................................. 143 iv Appendix III: SIM Focus Group Guide ................................................................................................... 147 Appendix IV: Faction Map ..................................................................................................................... 151 Appendix V: Financial Cost Estimation.................................................................................................. 157 Appendix VI: SIM Intervention Model .................................................................................................. 158 Appendix VII: SIM Intervention Model Assumptions ............................................................................ 159 Appendix VIII: In-Depth Interview Guide .............................................................................................. 168 Appendix IX: WHI Member Survey Results ........................................................................................... 171 Appendix X: Additional Quotations ...................................................................................................... 176 Appendix XI: Acronyms ......................................................................................................................... 182 v List of Figures with Captions Figure 1. Timeline of DELTA Activities………………………………………………..….59 Figure 2. WHI 2016 Steering Committee Member Map…………………………………....80 Figure 3. SIM 2016 Member Map………………………………………………………..…89 Figure 4. WHI